Monday, January 25, 2010

I want you to reminisce to when you were 21. Remember those days? The good years. When nothing ached. When the bills weren't big. When your biggest decisions were what to wear, how to fix your hair, and who to go out with.

When you could pee without a struggle.

Now, hold on, don't assume this is about me. It's not. I'm way, way too young to worry about that problem just yet (I think I just heard my wife laughing).

This is about my next patient, a local 21 year-old college student.

I live in a town where we have four colleges. Really great, fantastic schools. As a result, though, a portion of our ER patient population are college kids not from this area. Anonymous kids who aren't afraid to come see us so we can cure their "drip" or "discharge." Well, at least until the next time. But, all in all, good normal kids.

So, imagine my surprise when a nurse walked into the nurses' station and asked me to urgently see her new patient. A man who couldn't urinate. A 21 year-old man who couldn't urinate. Now, we're used to the older male patients who can't urinate, but 21?

Well, at 21, there isn't much to hold the flow back. A UTI. An STD. A kidney stone. Trauma. Neurological disease. Medications. Crazy. I ran through my internal list as I approached his room.

I walked into the room to find a young man writhing in his cot. "Please cath me!" he exclaimed before I could even introduce myself. Now, this was a first for me. Go back to when you were 21 again and tell me if you knew what catheterizing even was (heck, I'm not sure I could have even spelled it!). How did this kid? And what was his story?

It turns out this was a heck of a nice kid who had this happen to him once before. He had a phobia about airplane bathrooms and urinating at 15,000 feet. He was on a return flight, after a visit to home, when he felt the urge to urinate, just as Murphy's Laws would dictate. Thinking ahead, he believed he would have enough time to relieve himself in the terminal once he landed and before catching his connecting flight. Wrong!

His airplane didn't land in time, instead circling in the air waiting for its clearance. This poor kid's kidneys didn't know this, though. They kept filtering his blood and dripping more and more urine through their connecting tubes into his bladder. A dripping faucet filling up the clogged sink. Drip. Drip. Drip. By the time the kid had landed an hour later, he was in misery.

With only five minutes to catch his connecting flight, he hobbled through the airport, passing several bathrooms. Can you imagine making such a decision? Should he keep running to make his connection or should he stop to urinate, miss his flight, and then sit around and wait for the next unknown connecting flight?

He opted to catch his connecting flight. He told me he spent half of the hour flight in the airplane bathroom trying to go, ignoring all the knocks. He was obviously unsuccessful. Even without a phobia, I wouldn't be able to relieve myself with someone knocking on the door, either. Ducking down from the low ceiling, rocking back and forth from turbulence, staring down at that ridiculous metal basin they call a toilet, and then multiple knocks on the door? Sorry, bud, no can do. They need to get some Depends dispensers!

An hour and a half later, he was my patient. I ran and got our portable bedside ultrasound and hurriedly placed its probe on this kid's belly. Sure enough, he had a bladder big enough to fill a backyard pool. Eight-feet deep, no less!

The bladder is a tricky organ. Once it is stretched enough from filling with urine, the nerve fibers convey to your brain the need to find the nearest bathroom, do not pass go, and relieve yourself. In this kid's case, though, his bladder continued to fill beyond its capabilities to contract. Thus, he had a bladder screaming at him but no longer able to squeeze out the urine. An "atonic bladder" for those of you hoping to answer the final question on Jeopardy someday. This can be quite an uncomfortable predicament. A catheter was his only answer.

The nurse, relishing her role as a patient advocate, hip-checked me out of the way the second I was done with my ultrasound. She had a catheter in her hand and she was ready to save another life (her second one that day if you count the dental pain patient she and I had treated earlier!).

Unfortunately, the nurse was unsuccessful in passing the "too-big" catheter into his bladder.

"Hey, Doctor K," she yelled loud enough for three rooms over to hear, "can you grab me the smallest catheter in the med closet or, better yet, a pediatric one?"

Say what? Are you kidding me? He's 21, for God's sake, don't insult his manhood this way! Where are all the understanding male nurses when you need one? I made a mental to tell the nurse that if I ever needed anything less than a garden hose for a catheter, she better not yell it out to the other rooms, thank you. If I'm being honest, though, if I do need a garden hose, I would be okay with her letting the whole ER know (that better not be my wife I hear laughing again!).

The nurse was successful in placing the smaller pediatric catheter in this patient and immediately, almost one liter of urine drained out. Before he was discharged, he had drained two liters of urine. Can you imagine? Two liters! I am not embellishing here, we have markers on the collecting bag. And let me tell you, the day I can fill a two-liter Coke bottle in one squirt is the day I'll win a pissing--oops, I mean bragging--contest!

The patient did awesome. As soon as the urine started flowing out, he was a different person. We tested him for a UTI, a kidney stone, and STDs and he passed with flying colors. That's my boy! We offered to let him wear the catheter home with a draining bag attached to his leg, but he refused.

"What, are you kidding me? You mean wear this thing to class tomorrow?" he asked incredulously. I understood completely. I could only imagine what a chick-magnet a catheter with a leg-bag would be in college. Picture it--biology class. Pretty girl on his left, speaking to him. "Excuse me, but is it me or does it smell like a nursing home in here?" A pause and then she'd continue. "And why is your left thigh so much bigger than your right?"

When he left, without his catheter, he couldn't have been more appreciative...and comfortable...and homesick.

As always, a big thank you for reading. Next post will be Wednesday, January 27. A shout-out to all of you who have blogrolled me, twittered me forward, and have left cool insightful comments. And to those who have nominated and are supporting me for the 2009 Medical Webblog Awards at MedGadget.com, I thank you. I am very humbled...

25 comments:

Came over to visit after you commented on my Handmade home and can I just say that you had me as a follower after the first post. You "about me" ends with "I am a writer" Yes, you are and even better, you tell a great story. There is a difference. Some writers can't but when they can, it makes for wonderful reading.

I am honored that you enjoyed my writing. I don't consider myself a good storyteller but honest? Yes, I am do write as honestly as I can. I hope it resonates with others.

As a twenty year old out-of-state college student, I understand his dilemma: pee or make the connection? After reading this, I might give a second thought to letting the connection win every time. However, I will not be running to the ER for “drip or discharge.” Oh, and I do know what catheterizing is and can sometimes spell it. :-) <>< Katie

I've been one of those people with the overly distended bladders and couldn't void on my own. In my case, it was post op day 3 from a bladder surgery. Couldn't void all night long, went to the ER at 6am in agony! The nurse who put in my foley was an ANGEL!!! (1.5 liters of urine in that bag.....yowsas! No wonder I was hurting so much!)

Interesting story. One other thought--he may benefit from referral to a psychiatrist or psychologist for a social phobia evaluation ("shy bladder" is often a symptom). There are effective non-medication and medication treatments.

A patient was admitted to our inpatient hospice unit from a hospital and was SEVERELY agitated. He was an elder with some dementia, and the hospital had been unable to manage his agitation. The admitting nurse put one hand on the patient's abdomen and knew what the problem was. And it was even more than 2 liters. No one had checked at the hospital. Poor gentleman, but he got a wonderful night's sleep that night once he was comfortable again.

If I ever am in the position to need a catheter, please please someone make sure they use the pediatric one on me. I'll admit it, I am a wimp.

In other news, the docs were talking about catheterizing my mom when she was in the hospital last week for renal failure. She was not a happy duck. Luckily, things turned around and she is no longer in renal failure and didn't have to have a catheter.

I, too, was wondering if there was a psych consult. I mean, I can understand holding it because of lack of facilities (hence my 6 dollar piss and the Arby's cup incident), but holding it because you're scared to pee in an air plane? That's got to be somewhere in the DSM IV...just sayin.

Wow...that's terrible. I can't imagine what that poor dude must have felt like; the only experience I have that would be close to this is when they make you sit around for an hour or so with a full bladder when you're having an ultrasound in that vicinity, and that can be extremely uncomfortable. I knew it had quite a capacity, but I didn't know it could stretch so much that you can't even empty without help. Ouch! And for the record, I hate catheters...but I suppose in this case it was a huge relief (no pun intended)!

Well let me start by saying at 21 I was married. So I couldn't really relate to what this young lad had to endure.

Now being a nurse I to have seen many a young patient have urinary rention for a variety of reasons...what I find funny doc is this....you took personal offense when the nurse shouted out she needed a smaller catheter...it was only you and maybe a few other staff memebers that knew it was a male she needed to catheterize...you personalized this..and commented on how you might feel had you been in his shoes...and that is not such a bad thing....the nurse should not have shouted out..she should have gone and got it herself...covered the patient stepped out got the equipment she felt necessary and continued with the task at hand.

Ah I am sure he will joke about this experience in later years....but the poor lad..if anything I think he need to have his phobia about urinating in public addressed..or he might find himself in your ER once again.

As a former shy bladder sufferer, I can well relate to the dilemma this young man faced.

I have been catheterized many times because of my inability to urinate in the presence of other people. I think my record for retaining urine is something like 36 hours. Eventually I learned to self-cath - the ultimate band-aid for people with a shy bladder.

For more information about this condition (medically known as paruresis), please visit the website of the International Paruresis Association at www.paruresis.org. An estimated 7% of the US population is thought to suffer from this disorder, which is treatable.

StorytellERdoc, the real stories are the best. Thanks for the laughs (it was hard not too, but I am glad that it all worked out on the end), and thanks for visiting my blog. Anna :)

PS If you ever have a story when a baby bites during breastfeeding and ends up in the ER please do, because I think I saw stars today which is unusual for the cloudy day, lol. Have a good week. Anna :)

Thank you for visiting my blog and leaving a comment. You write a good story. My mother is a retired RN and I enjoy a good medical story. When I was young I spent hours looking through her medical books. Vital Signs in the Discover magazine is one feature I read from start to finish. :)

Experience frames the present—if you have ever had a kidney or bladder infection, it may be hard to understand this young man's situation. However, I appreciate your questioning of his need to be cath'd, because why would this man know he needs this in the first-place?

In context, I was hospitalized at 6yrs. with a life-threatening white cell count of 1.4, which was later determined to be an allergy to Septra, a Sulpha drug that was used to treat the kidney infection. Think about vomiting water every 10 minutes. So, being in this state, my parents talked to my best friend's father, a physician with a chemist background, and thankfully identified Sulpha as the problem, and probably saved my life, or prevented the need for a Kidney transplant.

Poor guy! I'm in agony in the middle of my shift if I don't get a pee break! Sometimes I think seeing the relief on a patient's face after being cathed and draining 1+ L has got to be one of my favourite parts of ER nursing. Great post as always and congrats on the award :)

I have MS and an inability to void is one of my major symptoms. Such fun.

When I first got sick, before I learned to do it myself, I would go to the ER to get cathed and I would ask them to use a pedi cath. They would look at me like I had two heads and then shove a virtual fire hose practically up through the top of my head.

My husband wouldn't use the plane bathroom on his way to Vietnam and held it and was in agony. I know it was a ridiculous amount of hours. He ended up alright though ..it was a bowel movement and I don't know why he felt that way.

Back-To-Back Winner, 2009 & 2010 Best Literary Medical Weblog

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About Me

I am a father of three. I am an ER physician of 16 years. I am a son, a brother, an uncle, a cousin, a nephew, and a friend, always. I am an athlete. I am small-town. I live in a big town. I am from a large, forestry family. I miss my mother's voice. I enjoy life's simpler, mundane moments. I am humbled daily. I am privileged with many blessings in my life. I am a writer.

Disclaimer

The events and encounters described in this blog are for general discussion and amusement only. They should be considered fiction. Nothing written here should be constituted as medical advice. Although the events of this blog contain certain elemental truths, every attempt has been made to protect patient confidentiality. Names, dates, location, and identifying features have been changed or fictionalized for that reason. The author reserves the right to embellish to make a good story great. All opinions expressed herein are those of the author only. All content is copyright of the author. Please do not reproduce or copy in part or whole without his expressed permission.